Ashe County Free Medical Clinic, Inc.

Today's Date: (mm/dd/yy)

Personal Info:

Your First Name*, M.I., Last Name*

Address*

City*, State* & Zip*

Email*:

Day Phone*:

Evening Phone/Cell/Pager: (xxx-xxx-xxxx)

VOLUNTEER POSITIONS NEEDED: (see descriptions here)
PLEASE CHECK 1 OR MORE.

Physician Nurse RN/LPN Lab Tech MOA

Eligibility Intake Worker (Tuesday 5 -7)

Receptionist

Eligibity Interpreter (Tuesday 5-7) Clinic Interpreter

Housekeeper

Refreshment Team Chart Review

PA/FNP (please specify in comments below)

Pro Bono Physician Other (please specify in comments below)

Comments:

Other Info:

How many times per month are you willing to volunteer ?

Which Thursday(s) Do you prefer?

1st 2nd 3rd 4th 5th

Do you speak a foreign language(s)
(if yes, please specify)

If you are a medical professional, please indicate your job title (If RN, are you registered in NC?).

Are you currently employed? If yes, please state your employer, title and responsibilities

Would you be willing to have a background check? Yes No

or THANK YOU!